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My internship is in an agency that charges sliding scale fees. One of my clients hasn’t paid for the last two sessions, saying he forgot his check both times. I know he can afford it because he just came back from a big vacation to Hawaii. How can I bring this up with him and get him to pay on time?

This is a difficult clinical issue, and it’s a good experience to have during your training. If you plan to work in a private practice after licensure, you will find that the meaning and emotions associated with client payment and fees become more complicated when it represents your income and livelihood. Having this experience while you are in training and not dependent on the fees for income allows you to come to a better understanding of the issues involved for you as well as your clients.

I recommend that you approach the exploration of money and fees by reflecting first on the meaning and emotions that are present for you both personally and professionally. Often money is a way of expressing and experiencing value or validation, and it may be used as a tool to exert interpersonal power. Feelings related to self-worth are often associated with the exchange of money in a relationship. These may include entitlement, comfort, envy, shame, deprivation, and pride. Think about the role that money plays in your family relationships and the meaning of money in your cultural community. You may become aware of implicit messages like “it’s not polite to talk about money,” “you have to fight for everything you get,” “you’re only worth what people give you,” or “if you work hard enough you’ll get what you deserve.”

In addition to your personal and cultural history with money, your current status as a therapist in training includes complex relationships with money. You may have taken on significant student loan debt or received support from a partner or family member. You are probably working as a volunteer or receiving a small salary while you are accumulating hours toward licensure, and you may be working another job in or outside the mental health field to pay your expenses. All of these factors will contribute to the feelings that arise in you when your clients pay or don’t pay their assigned fees. These will become heightened when you are in a private practice and your client fees are a source of income.

Once you have become more clear about how money impacts you in your clinical work, you can move to reflecting on the meaning of money for your client. Some of the things to consider are his early family experiences related to money, value, and power; cultural messages related to money and gender, since there may be different expectations for men and women; the meaning it has for him to seek services at an agency that offers a sliding scale; and the emotions associated with his financial choices. Think about conversations and interactions you have had in setting his fee, in sessions when he brings payment and when he doesn’t, and when he tells you about purchases or expenses like his recent vacation.

Your understanding of how you and your client think and feel about money will help you begin to identify the relational and cross-cultural dynamics in this therapy relationship and specifically in his recent lack of payment. A few possibilities to consider are: your client feels shamed by requesting a sliding scale fee and manages his shame by withholding payment; you are reluctant to discuss money openly and have had difficulty setting an appropriate fee and clear expectations about payment; your client devalues his emotions and needs for nurturing leading him to forget payment for a service that involves both emotions and needs for nurturing; your client associates masculinity with interpersonal power and is attempting to balance the power differential. What is important in your examination is to consider the contribution that you and the client are each making to this current conflict which will help you identify what you need to do internally and interpersonally to address your client’s lack of payment.

It may be helpful to use some of the guidance in a prior blog post about client attendance to identify a therapeutic response to your client forgetting his payment. Attendance and payment are two therapeutic frame issues that are often avenues for clients to repeat problematic relational patterns, especially those they aren’t able to articulate directly.

I hope you are able to use these suggestions in understanding clinical issues related to money. Please email me with comments, questions, or suggestions for future blog topics.

I had a session today in which a client asked to see the notes I have taken that are part of her chart. I told her I’d have to talk to my supervisor because I’ve never had a client ask for this before. What choices do I have in deciding whether to give her the notes or not?

This issue was addressed by HIPAA, which created a national standard for client’s access to all medical records including records of psychotherapy. Under HIPAA, the record belongs to the client and s/he has a right to request and receive a copy. Exceptions are only made for instances where viewing the record would cause serious harm to the client and, in the case of child records requested by parents, harm to the psychotherapy relationship. Most behavioral health agencies ask clients to make a written request and then provide a copy of the records within 1-3 weeks.

While HIPAA addresses client access to records from an administrative perspective, it doesn’t address the clinical issues that are often present when a client requests a copy of the current treatment record. Your supervisor can be helpful in talking through the meaning and motivation for your client bringing this up with you. Some factors to consider are the client’s previous experiences of secrecy and betrayal, issues of control and helplessness, interpersonal suspiciousness, and involvement in a legal case or application for disability. Your client is more likely to tell you about the reasons she wants to see your notes if you make it clear first that you plan to honor her request. In your next session, you can say “You told me last week you wanted to see the notes I have written for your chart. I have the written request here for you to fill out, and I also am interested in what led you to ask for the notes.” You can explore this further, if the client is willing to do so, by asking what she expects to see in the notes and how she feels about looking at them.

Most clinicians, especially those in field placement or practicum training, feel anxiety when a client requests the record. You may anticipate, correctly or incorrectly, that the client will be upset or offended by things you have written in progress notes or the assessment. Your assessment may include a diagnosis and case formulation that you haven’t explicitly shared with the client. Your notes may accurately reflect some of the client’s obstacles to improvement and progress. It is usually helpful to look at the record and to have your supervisor review it to identify anything that could be problematic. Whether or not you anticipate a negative reaction from the client, it is usually wise to say “There may be portions of this record that spark questions or upsetting feelings for you. I’d like to talk with you about anything that comes up after you’ve read it.” Then you should follow up with a discussion in the following session about what it was like for her to look at her record. If she has questions or was distressed by anything you wrote, I recommend being straightforward in your explanation. If you regret anything you wrote, you can acknowledge that you wish you had used different wording or had described the situation differently. In addition to negative feelings, she may feel pleased with her self-assertion and have an increased sense of empowerment when you respond to her request in a respectful, professional manner.

I hope you find this helpful in handling client requests for records. Please email me with comments, questions or suggestions for future blog topics.